Demographic and clinical factors associated with different antidepressant treatments: a retrospective cohort study design in a UK psychiatric healthcare setting

Objective: To investigate the demographic and clinical factors associated with antidepressant use for depressive disorder in a psychiatric healthcare setting using a retrospective cohort study design. Setting: Data were extracted from a de-identified data resource sourced from the electronic health records of a London mental health service. Relative risk ratios (RRRs) were obtained from multinomial logistic regression analysis to ascertain the probability of receiving common antidepressant treatments relative to sertraline. Participants: Patients were included if they received mental healthcare and a diagnosis of depression with antidepressant treatment between March and August 2015 and exposures were measured over the preceding 12 months. Results: Older age was associated with increased use of all antidepressants compared with sertraline, except for negative associations with fluoxetine (RRR 0.98; 95% CI 0.96 to 0.98) and a combination of two selective serotonin reuptake inhibitors (SSRIs) (0.98; 95% CI 0.96 to 0.99), and no significant association with escitalopram. Male gender was associated with increased use of mirtazapine compared with sertraline (2.57; 95% CI 1.85 to 3.57). Previous antidepressant, antipsychotic and mood stabiliser use were associated with newer antidepressant use (ie, selective norepinephrine reuptake inhibitors, mirtazapine or a combination of both), while affective symptoms were associated with reduced use of citalopram (0.58; 95% CI 0.27 to 0.83) and fluoxetine (0.42; 95% CI 0.22 to 0.72) and somatic symptoms were associated with increased use of mirtazapine (1.60; 95% CI 1.00 to 2.75) relative to sertraline. In patients older than 25 years, past benzodiazepine use was associated with a combination of SSRIs (2.97; 95% CI 1.32 to 6.68), mirtazapine (1.94; 95% CI 1.20 to 3.16) and venlafaxine (1.87; 95% CI 1.04 to 3.34), while past suicide attempts were associated with increased use of fluoxetine (2.06; 95% CI 1.10 to 3.87) relative to sertraline. Conclusion: There were several factors associated with different antidepressant receipt in psychiatric healthcare. In patients aged >25, those on fluoxetine were more likely to have past suicide attempt, while past use of antidepressant and non-antidepressant use was also associated with use of new generation antidepressants, potentially reflecting perceived treatment resistance

Augmentation of clozapine with ECT: a retrospective case analysis

Objective:We sought to assess the effectiveness of clozapine augmentation with ECT (C+ECT) in patients with clozapine-resistant schizophrenia. Methods:We conducted a retrospective review of electronic health records to identify patients treated with C+ECT. We determined the response to C+ECT and the rate of rehospitalisation over the year following treatment with C+ECT. Results:Forty-two patients were treated with C+ECT over a ten year period. The mean age of the patients at initiation of ECT was 46.3 (SD=8.2) years (range 27-62 years). The mean number of ECTs given was 10.6(SD = 5.3)(Range 3-25) with the majority receiving twice weekly ECT. Seventy six percent of patients (n=32) showed a Clinical Global Impression improvement score (CGI-I) of≤3 (at least minimally improved) following C+ECT. The mean number of ECT treatments was 10.6 (SD = 5.3) (range 3-25) with the majority receiving twice weekly ECT. Sixty four percent of patients experienced no adverse events. Response to C+ECT was not associated with gender, age, duration of illness, or duration of clozapine treatment.Seventy five percent of responders remained out of hospital over the course of one-year follow up, while 70% of those with no response to C+ECT were not admitted to hospital. Three patients received maintenance ECT, one of whom was rehospitalised. Conclusion:This study lends support to emerging evidence for the effectiveness of C+ECT in clozapine resistant schizophrenia. These results are consistent with the results of a meta-analysis and the only randomised controlled trial (RCT) of this intervention. Further RCTs are required before this treatment can be confidently recommended

Associations of presenting symptoms and subsequent adverse clinical outcomes in people with unipolar depression: a prospective natural language processing (NLP), transdiagnostic, network analysis of electronic health record (EHR) data

Objective: To investigate the associations of symptoms of mania and depression with clinical outcomes in people with unipolar depression. Design: A natural language processing electronic health record study. We used network analysis to determine symptom network structure and multivariable Cox regression to investigate associations with clinical outcomes. Setting: The South London and Maudsley Clinical Record Interactive Search database. Participants: All patients presenting with unipolar depression between 1 April 2006 and 31 March 2018. Exposure: (1) Symptoms of mania: Elation; Grandiosity; Flight of ideas; Irritability; Pressured speech. (2) Symptoms of depression: Disturbed mood; Anhedonia; Guilt; Hopelessness; Helplessness; Worthlessness; Tearfulness; Low energy; Reduced appetite; Weight loss. (3) Symptoms of mania or depression (overlapping symptoms): Poor concentration; Insomnia; Disturbed sleep; Agitation; Mood instability. Main outcomes: (1) Bipolar or psychotic disorder diagnosis. (2) Psychiatric hospital admission. Results: Out of 19 707 patients, at least 1 depression, overlapping or mania symptom was present in 18 998 (96.4%), 15 954 (81.0%) and 4671 (23.7%) patients, respectively. 2772 (14.1%) patients subsequently developed bipolar or psychotic disorder during the follow-up period. The presence of at least one mania (HR 2.00, 95% CI 1.85 to 2.16), overlapping symptom (HR 1.71, 95% CI 1.52 to 1.92) or symptom of depression (HR 1.31, 95% CI 1.07 to 1.61) were associated with significantly increased risk of onset of a bipolar or psychotic disorder. Mania (HR 1.95, 95% CI 1.77 to 2.15) and overlapping symptoms (HR 1.76, 95% CI 1.52 to 2.04) were associated with greater risk for psychiatric hospital admission than symptoms of depression (HR 1.41, 95% CI 1.06 to 1.88). Conclusions: The presence of mania or overlapping symptoms in people with unipolar depression is associated with worse clinical outcomes. Symptom-based approaches to defining clinical phenotype may facilitate a more personalised treatment approach and better predict subsequent clinical outcomes than psychiatric diagnosis alone

Inpatient use and area-level socio-environmental factors in people with psychosis

Purpose: There is consistent evidence that socio-environmental factors measured at an area-level, such as ethnic density, urban environment and deprivation are associated with psychosis risk. However, whether area-level socio-environmental factors are associated with outcomes following psychosis onset is less clear. This study aimed to examine whether the number of inpatient days used by people presenting to mental health services for psychosis was associated with five key area-level socio-environmental factors: deprivation, ethnic density, social capital, population density and social fragmentation. Methods: Using a historical cohort design based on electronic health records from the South London and Maudsley NHS Trust Foundation electronic Patient Journey System, people who presented for the first time to SLAM between 2007 and 2010 with psychosis were included. Structured data were extracted on age at presentation, gender, ethnicity, residential area at first presentation and number of inpatient days over 5 years of follow-up. Data on area-level socio-environmental factors taken from published sources were linked to participants’ residential addresses. The relationship between the number of inpatient days and each socio-environmental factor was investigated in univariate negative binomial regression models with time in contact with services treated as an offset variable. Results: A total of 2147 people had full data on area level outcomes and baseline demographics, thus, could be included in the full analysis. No area-level socio-environmental factors were associated with inpatient days. Conclusion: Although a robust association exists between socio-environmental factors and psychosis risk, in this study we found no evidence that neighbourhood deprivation was linked to future inpatient admissions following the onset of psychosis. Future work on the influence of area-level socio-environmental factors on outcome should examine more nuanced outcomes, e.g. recovery, symptom trajectory, and should account for key methodological challenges, e.g. accounting for changes in address

Services for people at high risk improve outcomes in patients with first episode psychosis

OBJECTIVE: About one‐third of patients referred to services for people at high risk for psychosis may have already developed a first episode of psychosis (FEP). We compared clinical outcomes in FEP patients who presented to either high risk or conventional mental health services. METHOD: Retrospective study comparing duration of hospital admission, referral‐to‐diagnosis time, need for compulsory hospital admission and frequency of admission in patients with FEP who initially presented to a high‐risk service (n = 164) to patients with FEP who initially presented to conventional mental health services (n = 2779). Regression models were performed, controlling for several confounders. RESULTS: FEP patients who had presented to a high‐risk service spent 17 fewer days in hospital [95% CI: −33.7 to (−0.3)], had a shorter referral‐to‐diagnosis time [B coefficient −74.5 days, 95% CI: −101.9 to −(47.1)], a lower frequency of admission [IRR: 0.49 (95% CI: 0.39–0.61)] and a lower likelihood of compulsory admission [OR: 0.52 (95% CI: 0.34–0.81)] in the 24 months following referral, as compared to FEP patients who were first diagnosed at conventional services. CONCLUSION: Services for people at high risk for psychosis are associated with better clinical outcomes in patients who are already psychotic

Defining severity of personality disorder using electronic health records: short report

Severity of personality disorder is an important determinant of future health. However, this key prognostic variable is not captured in routine clinical practice. Using a large clinical data-set, we explored the predictive validity of items from the Health of Nation Outcome Scales (HoNOS) as potential indicators of personality disorder severity. For 6912 patients with a personality disorder diagnosis, we examined associations between HoNOS items relating to core personality disorder symptoms (self-harm, difficulty in interpersonal relationships, performance of occupational and social roles, and agitation and aggression) and future health service use. Compared with those with no self-harm problem, the total healthcare cost was 2.74 times higher (95% CI 1.66–4.52; P < 0.001) for individuals with severe to very severe self-harm problems. Other HoNOS items did not demonstrate clear patterns of association with service costs. Self-harm may be a robust indicator of the severity of personality disorder, but further replication work is required